Provider Demographics
NPI:1104004746
Name:JACKSON, CANDIS L (LMHC: CAP)
Entity Type:Individual
Prefix:MS
First Name:CANDIS
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMHC: CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3460 DEPEW AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-7015
Mailing Address - Country:US
Mailing Address - Phone:941-764-6300
Mailing Address - Fax:941-764-7297
Practice Address - Street 1:3460 DEPEW AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-7015
Practice Address - Country:US
Practice Address - Phone:941-764-6300
Practice Address - Fax:941-764-7297
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4441101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health